Author Joan Ryan hugs her son Ryan in the courtyard of their Marin County home. Ryan's new book deals with her son's skateboard accident and long recovery after a head injury that he continues to struggle with, as he makes plans to attend college in the fall on the east Coast. Aug 21, 2009 less

Author Joan Ryan hugs her son Ryan in the courtyard of their Marin County home. Ryan's new book deals with her son's skateboard accident and long recovery after a head injury that he continues to struggle with, ... more

Photo: Lance Iversen, The Chronicle

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Ryan Tompkins at the Kentfield Rehabilitation Hospital in October 2006

Ryan Tompkins at the Kentfield Rehabilitation Hospital in October 2006

Photo: Joan Ryan, Special To The Chronicle

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Author Joan Ryan and her son Ryan visit the Rehabilitation Specialty Hospital in Marin County where he spent months in rehab with Mike Clark left who is a physical Therapist and Dowie Navarro right a Physical Therapist aid. Ryan's new book deals with her son's skateboard accident and long recovery after a head injury that he continues to struggle with. Aug 21, 2009 less

Author Joan Ryan and her son Ryan visit the Rehabilitation Specialty Hospital in Marin County where he spent months in rehab with Mike Clark left who is a physical Therapist and Dowie Navarro right a Physical ... more

Photo: Lance Iversen, The Chronicle

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Barry Tompkins pushes son Ryan along the Kentfield bike trail, with help from family dog, Bill.

Barry Tompkins pushes son Ryan along the Kentfield bike trail, with help from family dog, Bill.

Photo: Joan Ryan, Special To The Chronicle

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The Tompkins family visited the Marin Art and Garden Center in Ross in December 2008. From the left, Barry Tompkins, Ryan Tompkins, Joan Ryan and the family dog, Bill.

The Tompkins family visited the Marin Art and Garden Center in Ross in December 2008. From the left, Barry Tompkins, Ryan Tompkins, Joan Ryan and the family dog, Bill.

Photo: Muse Studios, Special To The Chronicle

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Joan Ryan with her son, Ryan Tompkins, when he was about eight months old, during a vacation in Kalui in 1991

Joan Ryan with her son, Ryan Tompkins, when he was about eight months old, during a vacation in Kalui in 1991

Photo: Barry Tompkins, Special To The Chronicle

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Bill Viola

Bill Viola

Photo: Kira Perov

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2nd excerpt from Joan Ryan's 'Water Giver'

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Joan Ryan is an award-winning journalist and author who lives in Marin County. She worked as a sports and news columnist at the San Francisco Examiner, then The Chronicle, from 1985 to 2007. Ryan's new book, "The Water Giver" (Simon & Schuster), from which this excerpt is taken, is the story of her 16-year-old son's near-fatal accident and how it changed her as a mother. The first part ran Tuesday.

August 16, 2006

There was no blood. No obvious injury.

When I drove up to the scene, Ryan was straining against the straps of the stretcher, surrounded by police and paramedics. He had been stripped to his boxer shorts and wore an immobilizing collar around his neck. Three neighborhood boys had raced to our house on their bikes to tell us Ryan fell off his skateboard three blocks away.

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"As soon as he's fixed up, I'm going to kill him," I joked.

The officer laughed. "If I don't get to him first."

The paramedic crouching over Ryan said he had no broken bones, but because he had hit his head, they were taking him to the hospital to be checked. Ryan said the right side of his head was the only place that really hurt.

My stomach didn't lurch. My heart didn't stop. I didn't feel what I had always heard you felt in the moment that your life changes.

The Marin General waiting room was empty. We filled out paperwork and took seats in front of the aquarium. Fifteen minutes passed. Thirty.

Finally a white-haired doctor appeared from behind the automatic double doors. He said Ryan was still being settled, that someone would come get us soon. I checked my watch. How long does it take to settle one kid?

Another 15 minutes.

Then a middle-aged woman emerged from the double doors. She asked if we were Ryan's parents.

I looked at the job title on her name tag.

Chaplain.

'What's going on?'

The chaplain walked us out of the Marin General waiting room, down a short hallway, and into her office.

"What's going on?" I asked, my heart pounding. "Why are we talking to a chaplain?"

She said a whole team is summoned when there is a "full trauma." A surgeon, an anesthesiologist, a chaplain. She listed others that I don't remember now.

"What do you mean a full trauma?" Barry asked.

"He bumped his head," I said.

The doctor knocked lightly on the door. He didn't sit. He said Ryan had sustained a significant head injury and had been put into a drug-induced coma. He led us down the hall into the large ER hub with counters and computers in the center and curtained rooms along the walls. The doctor pulled back a curtain. Ryan was in a blue hospital gown. His long body filled the bed. His head was wrapped in white gauze. He had a thick tube protruding from his mouth; it was attached to a machine that was helping him breathe. Two IVs snaked from his arms and connected to clear bags of liquid hanging from a metal stand.

The doctor explained that during the ambulance ride Ryan had become disoriented and agitated, classic signs of a traumatic brain injury. He had a significant bleed.

Ryan had surgery that night to remove the clot and was moved to the intensive care unit. Over the next nine days, doctors struggled to control the swelling in Ryan's brain. Dr. Mark Eastham, the neurosurgeon on call that week at Marin General, explained that when the brain swells, it pushes against the skull. He said to think about getting hit in the eye. The tissue around the eye can swell up as much as it wants because the skin is elastic. The skull is hard and fixed. There is no give. The more the brain swells, the more the pressure builds inside the skull.

Pressure on brain

This is measured by a fiber-optic intracranial pressure probe, which had been threaded through a hole drilled into Ryan's skull. If the pressure gets too high, the blood vessels are squeezed to the point of closing, causing brain damage or death.

The swelling became so severe that Eastham had to remove part of Ryan's skull to allow the brain to swell up and out, like bread rising in a pan. The removed "bone flap," as the piece of skull is called, was stored at a tissue bank until Ryan's brain had healed and the flap could be reattached with titanium rivets. But the swelling continued. At one point, Ryan's pupil "blew": It had become fixed and dilated. The brain seemed to be heading toward the brain stem.

"It could mean brain death," a nurse told us.

My heart drummed inside my ears. I looked at Barry. His mouth was slack. His eyes were wide and terrified.

Until that moment, I didn't know that I could not survive without him. It seemed almost unbelievable that I had forgotten how intensely I loved him. I had forgotten. I had always loved him. I knew that. But how long had it been since I had felt it? Since it had enveloped me? Since I had enveloped him in it? How much time had I squandered? I thought about the battles. The judgments. The disappointments. The crusty bits of resentments and frustrations I let build up around me like a carapace, providing myself a convenient refuge from his rejections and my failures, hardening whatever motherly instincts I once might have possessed.

I don't remember how long Ryan was in surgery. Forever. Eastham removed the other side of Ryan's skull. Ryan was stable but still critical. The next day we moved to UC San Francisco, which had a pediatric ICU and a whole staff of neurosurgeons rather than just one.

Awakening from coma

A week later, Ryan awoke from his coma, unable to swallow, speak or move his left side. "Ryan, sweetie, it's mom. I've been missing you." I felt another squeeze.

We were in Room Three inside the sixth-floor pediatric ICU.

"Ryan, are you ready to wake up? Open your eyes, sweetie."

Ryan turned his head toward my voice. His eyes opened. He looked at me, his gaze as cloudy as a newborn's. His face was impassive, completely frozen, either from the narcotics or the brain injury.

"Sweetie-pie, how are you feeling?"

He raised his right hand as if trying to reach me. Now I was certain he recognized me. I took his palm and pressed it against my lips.

"You've been sleeping for a really long time."

Like a baby, he soon began exploring, reaching for everything in his sight: the IV in his arm, the nurse's hair, the bags of fluids on the metal pole by his bed. The nurse gave him the suction wand to play with. It is similar to the one dentists use to clear out saliva. Ryan couldn't swallow, so thick sticky gunk - it looked like white rubber cement - collected in his mouth and had to be suctioned out several times an hour.

Ryan waved the wand around, then stuck it in his ear. He pulled it out, then tried it again, exploring the strange suctioning sensation.

Over the next several days, Ryan began to hold up one finger for yes in response to our questions. He still couldn't speak. But every new gesture was evidence that Ryan's brain was rebooting, that a sentient being was inside there. He was sweet and affectionate, like a baby who wanted nothing more than to be cuddled and stroked.

Trying to mimic words

One day, when Barry was joking with Ryan, the right corner of Ryan's mouth turned up. He was smiling. His left side was still paralyzed, so the smile was weak and lopsided but thrilling enough to turn Barry and me into Catskills comics to get him to do it again. I told him that, with all the gunk in his throat - he still was too weak to cough - his breathing sounded like Darth Vader.

"I am your fah-tha," I said, dropping my voice an octave.

Ryan tried to mimic the words, parting his lips. But no sound would come. I joked that Dad and I would look back on this period of muteness with wistful longing. The rest of the day, Ryan kept moving his mouth, itching to talk.

When we left that night, Barry kissed Ryan a dozen times on his cheeks and forehead and told him we'd be back in the morning. As Barry gathered the newspapers and cell phones, I bent and kissed Ryan and told him I loved him then laid my cheek against his.

I felt his dry lips on my ear. And I heard his first word - light, raspy, barely audible.